The guideline on the management of opioid use disorders by Bruneau and colleagues1 is excellent; however, they omitted monthly injectable naltrexone. The authors did review use of the oral formulation of this opioid antagonist, which they correctly graded as a weak recommendation based on low-quality evidence. In contrast, two recent randomized controlled trials showed that extended-release naltrexone was effective similarly to buprenorphine–naloxone for retention in treatment and reduction in drug use once initiated postdetoxification.2,3 Importantly, extended-release naltrexone is cost-effective overall4 and can also treat alcohol use disorders.5 Patients taking extended-release naltrexone have no euphoria or physical dependence, which makes it an attractive choice for those with safety-sensitive work.
The US Food and Drug Administration authorized extended-release naltrexone in 2010. The national practice guideline for the treatment of opioid use disorders from the American Society of Addiction Medicine recommends the use of extended-release naltrexone.6 This position is supported by Dr. Nora Volkow, Head of the US National Institute on Drug Abuse.7
Since April 2017, Health Canada has allowed prescription of extended-release naltrexone under a special dispensation for urgent public need.8 Unfortunately, no public funding has been put in place to support this abstinence-based treatment. Bruneau and colleagues note, “The evidence base for pharmacotherapies not yet widely available in Canada, including long-acting and extended-release opioid antagonists … was not reviewed in this guideline.” This omission may dissuade future funding, which would make one of the few proven treatments for opioid use disorders unaccessible to Canadians.
Footnotes
Competing interests: None declared.
References
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